Improving

Fall Risk
Assessment
in Home Care

The Timed Up and Go (TUG) is a popular, effec-

tive, and valid test of functional mobility and fall
risk that is often completed by registered nurses
(RNs) and physical therapists (PTs) throughout the
Interdisciplinary
course of a home care episode. As reimbursement
becomes tied to outcomes, it is essential that all
disciplines are consistent in their methods when
Use of the Timed
Up and Go (TUG)
administering the TUG. Results of this study con-
firm the hypothesis that test-specific training will
significantly improve reliability of the TUG when
completed by 2 different disciplines. The purpose
of this article is to describe an initiative that pro-
vided tool-specific training to all clinical staff at
our home care agency. The inter-rater reliability
Kristen Murphy, PT, MS, DPT, and
between PTs and RNs improved significantly from Susan Lowe, PT, DPT, MS, GCS, CEEAA
0.77 to 0.86 (p = 0.001) after standardized training
on administration of the TUG.

vol. 31 • no. 7 • July/August 2013 Home Healthcare Nurse 389

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Introduction
Fall Risk Assessment and Outcome and
Assessment Information Set
In 1999, the Centers for Medicare and Medicaid
Services (CMS) began requiring all Medicare-
certified home healthcare agencies (HHAs) to col-
lect and report performance data using a tool
called Outcome and Assessment Information Set
(OASIS) (Centers for Medicare & Medicaid Ser-
vices, 2012a). The data collected are meant to
represent the core items needed for a comprehen-
sive assessment of adult patients receiving home
care services (Centers for Medicare & Medicaid
Services, 2012a). The information can be used by
the HHA and CMS to measure patient outcomes
and to assist with outcome-based quality improve-
ment. In addition to providing for patient assess-
ment and outcomes, OASIS data can and should
be used for care planning. In 2010, OASIS-C was
rolled out as the latest version of the data set.
OASIS-C added process measures related to fall
risk assessment and prevention.
Process quality measures are used to assess
the rate of completion of specific evidence-based
processes of care for high-risk, high-volume,
problem-prone areas. Fall risk is one of these
areas (Centers for Medicare & Medicaid Services,
2012b). Although not required, CMS tracks and
incentivizes HHAs to complete a fall risk assess-
ment using a tool that is valid, standardized, and
multifactorial. The completion of this fall risk as-
sessment is documented in OASIS question
M1910 (Table 1). Failure to complete a multifac-
tor fall risk assessment will negatively impact the
agency’s process measure report. Public report-
ing of this finding is expected to encourage HHAs
to follow best practices for fall prevention and
assessment (Anamaet & Krulish, 2011). The
Timed Up and Go (TUG) test is commonly used
Table 1. Outcome and Assessment
Information Set Question M1910
M1910 Has This Patient Had a Multifactor Fall Risk
Assessment (e.g., Falls History, Use of Multiple
Medications, Mental Impairment, Toileting
Frequency, General Mobility/Transferring
Impairment, Environmental Hazards)?
0 No multifactor falls risk assessment conducted
1 Yes, and it does not indicate a risk for falls
2 Yes, and it does indicate a risk for falls
Source: Data from Centers for Medicare & Medicaid Services,
2012b.
390 Home Healthcare Nurse
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as a tool, along with assessment of at least one
other nonmobility risk factor, to meet the criteria
for question M1910 (Anamaet & Krulish, 2011).
Literature Review
Using the TUG to Determine Fall Risk
The TUG is a simple, effective, and common test of
functional mobility. The TUG assesses a subject’s
ability to stand up, walk 3 m, turn, walk another
3 m, and then sit back down. It can provide a quick
assessment of functional strength, ability to ambu-
late, and dynamic balance (Podsiadlo & Richard-
son, 1991). A great amount of clinical information
can be learned from the TUG. Normative reference
values are available by age to determine above
and below average scores (Bohannon, 2006).
Extended TUG times have been shown to be pre-
dictive of difficulty with activities of daily living
(Wennie Huang et al., 2010). Herman et al. (2011)
concluded that elevated TUG scores correlate
with early onset of mild cognitive decline. Alexan-
dre et al. (2012) found the TUG to be an accurate
measure for screening the fall risk in older adults,
using a cut-off score of 12.47 seconds. There are
several different cut-offs discussed in the litera-
ture but the Alexandre study is the most recent.
Inter-rater Reliability of the TUG
Reliability of the TUG is considered to be excellent
with an intraclass correlation (ICC) greater than
0.95 (Nq & Hui-Chan, 2005). It has been shown to be
reliable in a variety of clinical situations including
in cases of Parkinson’s disease with an ICC = 0.80
(Huang et al., 2011), dementia with an ICC of 0.90
(Blankevoort et al., 2013), and hip fracture after
surgery with an ICC of 0.95 (Kristensen et al., 2011).
The TUG is both sensitive and specific in re-
gards to identifying community-dwelling older
adults (CDOAs) that are at risk to fall (Shumway-
Cook et al., 2000). It has been shown to be sensi-
tive to change and to have good reliability among
clinicians of varying levels of experience
(Shumway-Cook et al., 2000). Researchers have
determined values for a minimally important
clinical difference ranging from 3.5 seconds in
patients with Parkinson’s disease (Huang et al.,
2011) to 6.2 seconds in patients who average an
initial time of 20 seconds (Kristensen et al., 2011).
Predictive Value of the TUG
Although there are consistent data about the
ability of the TUG to identify subjects with a past
www.homehealthcarenurseonline.com
history of falls, there is less conclusive evidence
about the ability of the TUG to predict future
falls. Beauchet et al. (2011) identified only one
study that found a significant association between
TUG time and future falls during their systematic
review. In their discussion, the variation of ad-
ministration of the TUG among the various stud-
ies was identified as a possible confounding fac-
tor. Bergmann et al. (2009) showed that procedural
differences, including verbal instructions,
distance marker, and chair type, can negatively
affect reliability of the TUG.
Importance of Good Reliability
Reliability of a clinical measure is one of the most
important characteristics of a test. Reliability is
the ability of a test score to be consistent when
repeated. A measure is thought to be reliable if
consistent scores are obtained under consistent
conditions. When analyzing the effectiveness of
therapy interventions, it is critical that the data
used to determine these outcomes are reliable.
Given the importance these data can have in de-
termining functional outcomes, it is imperative
that the testing be completed as described by
best practice guidelines. The value of the score is
only as good as the quality of the data.
Problem
Using TUG Scores to Determine Outcomes
Although the inter-rater reliability of the TUG is
good between physical therapists (PTs), there
does not appear to be any literature on the reli-
ability of the TUG between different disciplines.
The TUG test is often completed by nurses at
the initial nursing visit as part of the require-
ment to complete a multifactor fall risk assess-
ment. The degree to which the admitting nurse
or PT is trained in the administration of the TUG
varies between agencies. The variation in the
way the TUG is completed can be related to a
lack of consistent training. The TUG is a popular
test among PTs when it is time for reassessment.
There are frequent occurrences where a clini-
cian would like to compare the reassessment
TUG score to the score obtained at the admis-
sion visit for outcomes studies. For the purpose
of this study, outcomes are defined as the prog-
ress made on the TUG as the result of therapy. If
the initial TUG was completed by the nurse, can
the therapist use that score as a baseline to
determine progress?
vol. 31 • no. 7 • July/August 2013
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Methods
Pretest
One physical therapist (PT) and one registered
nurse (RN) administered the TUG to 15 CDOAs
without any specific instructions or training. The
home care agency had not completed any specific
training of the TUG for its clinical staff before this
study. The CDOAs were volunteers recruited from
an exercise class held at local senior center. The
volunteers were predominantly women (13 women
and 2 men) with an average age of 68 years. The
volunteers were divided into two groups. One
group completed the TUG with the nurse first and
then completed the TUG with the PT. The other
group completed the TUG initially with the PT and
then with the nurse. Each clinician had the CDOAs
complete a practice run-through of the TUG and
two timed trials of the TUG. The average of the two
trials was used for statistical purposes. The physi-
cal setup, including measurement of the 3-m
course, was established by the author and was
consistent for each clinician. The data were not
shared among clinicians. Inter-rater reliability was
determined between each discipline.
Training
One week later, the RN and PT participated in a
specific training session for administration of the
TUG. The training was completed in an agency-
sponsored training event offered to the entire
clinical staff (RNs, PTs, and occupational thera-
pists) of the HHA. The training protocol was
based on best practices as indicated in the CDC’s
“Tools to Implement the Otago Exercise
program”(National Center for Injury Prevention
and Control, 2012) (Table 2). A post-training ques-
tionnaire was filled out by all clinicians who par-
ticipated in the training session (Table 3). The
questionnaire surveyed the clinicians’ confidence
in administration of the TUG and perception of
the TUG before and after the training session.
Posttest
Five days after the training, the PT and the RN
administered the TUG to 15 different CDOAs
using the same procedure. Again, inter-rater
reliability was calculated between disciplines.
Results
There were no significant differences found be-
tween the two groups of CDOA that participated
in the TUG trials in terms of age or gender. The
Home Healthcare Nurse 391
inter-rater reliability of the TUG was calculated the TUG. The interdisciplinary reliability of the
by using the Pearson correlation coefficient. The TUG scores improved after standardized training
reliability of the TUG scores between the PT and (r = .86), indicating a level of consistency among
the nurse prior to the training session was 0.77, scores that is considered good (Portney &
indicating a level of consistency among the Watkins, 1993). The change in inter-rater reliability
scores that is good but not as high as the inter- was significant at a level of p = .001 (Figure 1).
rater reliability normally found when performing Observation analysis of the testing procedures
prior to training revealed several inconsistencies
Table 2. Standardized Timed Up and between the clinicians’ administration of the test.
Go Protocol Variations in verbal instructions included different
Standardized Verbal Instructions instructions regarding walking speed (normal or
fast pace) and the exact location to turn and return
When I say “Go,” I want you to: to the chair (walk past the line or walk to the line).
There was a lack of consistency between clinicians
1. Stand up from the chair.
2. Walk to the line on the floor at your normal pace. and between trials of the same clinician in regards
3. Turn. to exact start and stop time recorded via the stop-
4. Walk back to the chair at your normal pace. watch. Several different start times were used,
5. Sit back down again. including when the CDOA started to move, when
Standardized Timing Instructions the CDOA actually lifted off the chair, and when the
clinician said go. It was observed that during some
On the word “Go” begin timing. trials no command of “go” was given and the tim-
ing started when the CDOA started to move. Stop
Stop timing after patient has sat back down and record. times varied as well, though not to the same ex-
Time: ______________ (seconds) tent. After training, improved consistency of ver-
bal instructions and timing criteria was observed.

Table 3. Post-training Questionnaire

Please indicate your discipline RN PT

Please indicate your level of confidence when performing the TUG:

No Some Very
NA Confidence Confidence Confident Confident
0 1 2 3 4

Prior to this training, how confident were you in

your ability to complete the TUG properly? 0 1 2 3 4

After completing this training, how confident do

you feel in your ability to assess a patient's fall risk? 0 1 2 3 4

Not Somewhat Very

NA Likely Likely Likely Likely
0 1 2 3 4

After completing this training, how likely is it that you

will complete the TUG with your patients more often
than at start of care? 0 1 2 3 4

After completing this training, do you have a greater appreciation for the TUG? Yes No

Notes: PT = physical therapist; RN = reigstered nurse; TUG = Timed Up and Go test.

392 Home Healthcare Nurse www.homehealthcarenurseonline.com

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 Interdisciplinary Reliability: Pre- and Post-training
Pearson Correlation Coefficient (p = .001)
1
0.9
0.8
0.77
0.7
0.6
0.5
Pretest r value
Figure 1. Inter-rater reliability.
Discussion of Findings
Results of this study confirm the hypothesis that
test-specific training will significantly improve reli-
ability of the TUG test when completed by two dif-
ferent disciplines. The key to improved reliability
between disciplines appears to be specific instruc-
tion in best practice guidelines for proper physical
setup, verbal instructions, and timing criteria.
A Model for Mandatory Training
In-service training was provided to approxi-
mately 120 clinicians at Visiting Nurses & Health
Services of CT over the course of 1 day. The
staff was divided into groups of four to five clini-
cians who were assigned a specific training time
scheduled at 15-minute intervals. The RN and
PT who participated in the research study
attended this training event. Training consisted
of instruction in proper physical setup, verbal
instructions, and timing guidelines (Figure 2).
Groups of clinicians timed one volunteer sub-
ject as they walked the TUG. Scores were com-
pared between the clinicians. Clinicians were
deemed competent in administration of the TUG
when scores were within 0.5 seconds of each
other.
vol. 31 • no. 7 • July/August 2013
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0.86
Posttest r value
1. Consistent physical setup: As described in
the original study, Podsiadlo and Richardson
(1991) used an upright chair with a seat
height of 47 cm. In a patient’s home, it is
critical to find an appropriate chair from
which to start the test. Low couches, soft
recliners, or chairs without armrests are
not appropriate for use with the TUG. To
improve consistency of the measurement of
the 3-m walking course, 3-m lengths of string
were provided to all clinicians for use in the
home. Clinicians were instructed to use the
string to mark the course and then remove
the string for the actual test. It was assumed
that measuring 3 m in the home was a great
source of variability between clinicians.
Anecdotally, during the training sessions,
several clinicians attempted to confirm the
accuracy of pacing out 3 m with their own
steps only to be surprised at how poorly this
method correctly measures 3 m. Consistent
physical setup is crucial to reliable data.
2. Standardized verbal instructions: Podsiadlo
and Richardson (1991) published specific in-
structions to be used during the test (Table 2).
This wording is considered to be the standard.
Home Healthcare Nurse 393
 Without specific and standardized instruc-
tions, variability among scores will increase.
Patients are instructed to ambulate at a
“normal pace.” It is a common misconception
that the patient should be told to ambulate as
quickly as possible. The verbal instructions
also include directions to walk “to the line.”
There is no need to go past the line. Reliability
is greatly improved when patients are pro-
vided with the same instructions at all times.
3. Established timing criteria: Timing of the TUG
test should be completed with a stopwatch
or timer. A stopwatch feature can be found
on almost all cell phones. Use of the second
hand on a watch is not an acceptable method
of timing. Instructions for start and stop
times are very clear. Timing of the TUG test
should start on the word “Go.” It is important
to capture the patient’s ability to process
the command and react to it. Patients with
mild cognitive impairment may have delays
in the processing of this command and this
delay needs to be captured in the TUG score
(Herman et al., 2011). By starting the timing
on the word “Go,” the TUG is assessing a pa-
tient’s ability to rise from a chair in a timely
manner. As a patient’s strength improves and
the sit-to-stand transfer becomes easier, the
TUG score will reflect that improvement only
if the start time is accurate and consistent.
The timing should end when the patient has
returned to sitting and the back of the patient
contacts the back of the chair. By clearly
defining the exact moment to start and stop
the timing of the test, reliability of the TUG is
greatly improved.
TUG Scores for Outcome Studies
Without specific training, the inter-rater reliabil-
ity of the TUG, in this pilot study, is not adequate
to determine progress at time of reassessment. If
Standardized Standardized
Mandatory
Physical Set-
Training
Up Instructions
Figure 2. A model for clinician training.
394 Home Healthcare Nurse
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TUG scores obtained at admission by RNs are to
be compared to TUG scores obtained by PT at
time of reassessment, HHAs should be instituting
an education process for all staff to assure con-
sistency. The level of reliability can be adequate
for accurate reassessment of progress if the
recommendations identified are followed.
After training on the TUG, the interdisciplin-
ary reliability improved to the level of 0.86. This
is less than previously documented inter-rater
reliability between PTs. Kristensen et al. (2011)
reported an ICC of .95 in patients with hip frac-
ture. The inter-rater reliability was found to be
.91 in a study of the effect of cognitive deficits
on the TUG (Nordin et al., 2006). The difference
in the reliability between PTs and RNs may be
related to the experience and training PTs have
in movement observation and analysis. Addi-
tional methods of training may be beneficial,
including training with actual agency patients in
their own home. Future studies may be indi-
cated to further determine how interdisciplin-
ary reliability of functional screening tests can
be improved.
Clinician Confidence Pre- and Post-training
In an effort to assess the perceptions and confi-
dence level of the clinicians related to their abil-
ity to complete the TUG, 103 clinicians completed
a questionnaire after the training session—see
Table 3. Only 9% of RNs reported they were “very
confident” in their ability to administer the TUG
before the training session. In contrast, 100% of
the PTs reported they were “very confident” in
their administration of the TUG. After the train-
ing session, 83% of RNs surveyed responded as
being “very confident” in their ability to properly
complete the TUG—see Figure 3. Of these 83%,
62% stated they would now be more likely to
complete the TUG at time points other than at
the start of care as needed. Although the TUG is
Standardized
Reliable
Verbal Timing
Data
Criteria
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 Administering the TUG:
RN Confidence Before and After Training
100%
90% % Very Confident
80%
70%
60%
50%
40%
30%
20%
9%
10%
0%
Before Training
Notes: RN = registered nurse; TUG = Timed Up and Go test.
Figure 3. Clinician confidence.
a required part of the initial start of care visit for
this agency, the TUG can be used intermittently
as determined by the clinician to assess progress
and fall risk. One hundred percent of all clinicians
surveyed reported a greater appreciation for the
TUG and its clinical value after the in-service
training.
Limitations
This is a small pilot study that compared inter-
rater reliability between one PT and one RN.
Although the entire clinical staff of the agency
(RNs, PTs, occupational therapists) completed
the training, the interdisciplinary reliability was
calculated with one PT and one RN on a small
number of CDOAs. Future studies should include
a larger number of clinicians and subjects.
Another limitation was the use of healthy CDOAs
as compared to actual patients. Similarly, the TUG
test was completed in a controlled environment in
the community (a senior center) as compared to
in the home. Finally, this study addresses these
concerns in one agency within one state and the
results may not carry over across the country.
Discussion and Implications
The findings of the study indicate that home
healthcare clinicians should complete a TUG train-
ing program and pass a competency examination
vol. 31 • no. 7 • July/August 2013
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83%
After Training
based on best practice standards of administra-
tion of the TUG at time of initial hiring and annually
after that as a part of annual competencies. Consis-
tent verbal instructions, consistent timing guide-
lines, and consistent physical setup are required to
maximize reliability and the value of any outcomes
that use the TUG data. With adequate training,
initial TUG scores can be used for comparison at
time of reassessment regardless of which disci-
pline completed the test at start of care.
Need for Ongoing Research
Given the collaborative nature of healthcare, it is
imperative that adequate reliability is present in
all assessments that are completed by multiple
disciplines. Although the interdisciplinary reli-
ability of the TUG improved significantly with this
training program, there is still room for improve-
ment. Additional ways to improve consistency
across disciplines include training with actual
patients, training in the home environment, and
more frequent training. Future studies may want
to investigate not only the TUG but also other
valuable clinical tools that are commonly used
across disciplines and in the home.
Kristen Murphy, PT, MS, DPT, is a Physical Thera-
pist at Visiting Nurse & Health Services of CT, and
a recent Doctoral Graduate, CPS Bouve College of
Home Healthcare Nurse 395
Health Sciences, Northeastern University, Manchester,
Connecticut.
Susan Lowe, PT, DPT, MS, GCS, CEEAA, is
the Director of the Transitional DPT Program, CPS
Bouve College of Health Sciences, Northeastern
University, Boston, Massachusetts.
This article was submitted in partial fulfillment
of a doctorate of physical therapy degree for the
Bouve Institute, Northeastern University, Boston,
Massachusetts.
The authors extend special thanks to Dr. Susan
Lowe and Dr. Khalid Bibi of Northeastern University
for guidance with research design and statistical
analysis and to the management team and clinical
staff of Visiting Nurse & Health Services of CT for
support and active participation in the research
and training interventions.
The authors and nurse planners have disclosed
that they have no financial relationships related to
this article.
Address of correspondence: Kristen Murphy, PT,
MS, DPT, Visiting Nurses & Health Service of CT,
8 Keynote Dr., Vernon, CT 06066 (kristy.murphy@
snet.net).
DOI:10.1097/NHH.0b013e3182977cdc
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